Addiction Interaction Disorder: Understanding Multiple Addictions Patrick J. Carnes, Ph.D.

Gambling (N=103) 2

Alcoholism (N=740) 3

Substance Abuse (N=664) 4

Eating Disorder (N=213) 5

Addiction Interaction 6

Challenges to Recovery Addiction is a brain disease

Addiction is a brain disease expressed in the form of compulsive behavior. Alan I. Leshner, MD Former director of the National Institute on Drug Abuse

Nucleus Accumbens—Brain’s Reward Center Neurochemistry Nucleus Accumbens—Brain’s Reward Center Normal Obese Red indicates high number of receptors for dopamine People short of dopamine have difficulty feeling joy. Alcoholic Cocaine Hans Breiter, director of the Motivation and Emotion Neuroscience Center at Massachusetts General Hospital 9

DA Concentration (% Baseline) Natural Rewards Elevate Dopamine Levels 50 100 150 200 60 120 180 Time (min) % of Basal DA Output NAc shell Empty Box Feeding Source: Di Chiara et al. FOOD 100 150 200 DA Concentration (% Baseline) Mounts Intromissions Ejaculations 15 5 10 Copulation Frequency Sample Number 1 2 3 4 6 7 8 9 11 12 13 14 16 17 Scr Bas Female 1 Present Female 2 Present Source: Fiorino and Phillips SEX ©2008 Patrick J. Carnes, PhD 10 10

Effects of Drugs on Dopamine Levels 100 200 300 400 500 600 700 800 900 1000 1100 1 2 3 4 5 hr Time After Amphetamine % of Basal Release DA DOPAC HVA Accumbens AMPHETAMINE 100 200 300 400 1 2 3 4 5 hr Time After Cocaine % of Basal Release DA DOPAC HVA Accumbens COCAINE 100 150 200 250 1 2 3 hr Time After Nicotine % of Basal Release Accumbens Caudate NICOTINE 100 150 200 250 1 2 3 4hr Time After Ethanol % of Basal Release 0.25 0.5 2.5 Accumbens Dose (g/kg ip) ETHANOL Source: Di Chiara and Imperato 11

Common Language of Technological Change Internet sex as the “crack cocaine” of sexual compulsivity – Al Cooper Ph.D. Machine video poker as the “crack cocaine” of compulsive gambling – Robert Hunter, Ph.D.

Definition of a Black Hole: A celestial phenomenon when a massive star collapses from its own gravity. A black hole has such a strong pull that not even light can escape from it.

Addiction Interaction An addiction phenomenon where multiple addictions combine to overwhelm a person by their complexity and power. Phenomenon is so strong, no specific focus is strong enough to escape from it.

Challenges to Recovery Addiction is a brain disease Addiction can be the gateway to the pursuit of excellence

Challenges to Recovery Addiction is a brain disease Addiction can be the gateway to the pursuit of excellence Addiction often has a trauma component

265 Indicated Some Abuse (92.3%) ABUSE AND ADDICTION 265 Indicated Some Abuse (92.3%) (N=264) Sexual Physical Emotional No 11 35 17 ____ 63 23.9% Yes 31 60 110 ____ 201 76.1% No 26 51 36 ____ 113 42.8% Yes 16 44 91 ____ 151 57.2% No 7 10 4 ____ 21 8.0% Yes 35 85 123 ____ 243 92.0% One Addiction 2 – 3 Addictions 4+ Addictions

National Violence Against Women Survey Persons raped or physically assaulted in lifetime by sex of victim Women -- 55% or 55,383,350 Men -- 67% or 61,955,644 Last twelve months: Women -- (302,091) 1,913,243 Men -- (92,748) 3,153,432

NAVW Survey Seventy-six per cent of the women who were raped and/or physically assaulted since the age of 18 were assaulted by a current or former husband, cohabiting partner, or date. Another twenty six per cent knew their assailant. Only fourteen per cent were victimized by a stranger.

Compulsive Attachment: Key Characteristics Troubled people Hero and pathological giving High Intensity and Drama Boundary Collapse Impression Management Conflict Avoidance

“The addictive dependence on feelings of pain…” Alice Miller, The Drama of the Gifted Child

Addiction Interaction Disorder Addictions more than coexist, they interact, reinforce, become part of one another. They become packages.

Cross Tolerance A. Simultaneous increase in addictive behavior in two or more addictions. B. Transfer of a high level of addictive activity with little or no developmental sequence.

Withdrawal Mediation One addiction serves to moderate, relieve, or avoid withdrawal from another.

Replacement One addiction replaces another with majority of emotional and behavioral features.

Alternating Addiction Cycles Addictions cycle back and forth in a patterned systemic way.

Masking Addict uses one addiction to cover up for another, perhaps more substantive addiction.

Ritualizing Addictive behavior of one addiction serves as a ritual pattern to engage another.

Intensification Fusion dependence: neither addiction separately is sufficient; only simultaneous use is sufficient.

Intensification Partial Fusion: Addict combines addictions in such a fashion to be more potent than each addiction separately; addictions are used independently part of the time.

Intensification Binge Features: episodic multiple use, yet functionally independent of one another.

Numbing Addiction is used to medicate shame or pain caused by other addiction or addictive bingeing.

Disinhibiting One addiction is used to lower inhibitions for other addictive acting out.

Combining Mixing addictive experiences to moderate responses due to neuropathway interaction.

Addiction Interaction: Patient Recognition (N=650) Cross Tolerance – 59% Withdrawal Mediation – 59% Numbing – 59% Fusion –57% Masking – 56%

Addiction Interaction: Patient Recognition (N=650) Replacement – 47% Disinhibiting – 46% Ritualizing – 44% Combining – 38% Alternating Addiction Cycles –36%

Addiction Interaction Paradigm Changes: Diagnostic Framework: revision of DSM Treatment Process: depth and scope Treatment Focus: the underlying issues Relapse Prevention: addictions as packages Altered Strategies: first step, screen, neuropathways Mirror Patient Realities: professional allegiances

Challenges to Recovery Addiction is a brain disease Addiction can be the gateway to the pursuit of excellence Addiction often has a trauma component Addiction can take many forms Addiction treatment is difficult to access for many

Challenges to Recovery Addiction is a brain disease Addiction can be the gateway to the pursuit of excellence Addiction often has a trauma component Addiction can take many forms Addiction treatment is difficult to access for many Addiction and recovery interfere with advocacy

Additional Information 48

For more on the Certified Sex Addiction Therapist (CSAT) trainings, the task-centered approach to addiction recovery, and assessment testing for sexual, work and financial issues go to: www.IITAP.com or email Info@IITAP.com or call (480) 575-6853 49

Gentle Path Press For books, workbooks, CDs & DVDs on the subject of sex addiction and recovery, please visit: www.GentlePath.com or call (800)708-1796 50

SexHelp For additional information about Dr. Patrick Carnes, links to other resources, current topics in research, and popular literature, go to: www.SexHelp.com 51